Revisiting major anatomical risk factors of maxillary sinus lift and soft tissue graft harvesting for dental implant surgeons.

The anatomical variations of the maxillary sinus septa, greater palatine artery, and posterior superior alveolar arteries might cause unexpected complications when they are damaged. Dentists who know these structures well might hope to learn more practical knowledge to avoid and assess injury preoperatively. Therefore, this review paper aimed to review the reported anatomy and variations of the maxillary sinus septa, greater palatine artery/nerve, and posterior superior alveolar artery, and to discuss what has to be assessed preoperatively to avoid iatrogenic injury. To assess the risk of injury of surgically significant anatomical structures in the maxillary sinus and hard palate, the operator should have preoperative three-dimensional images in their mind based on anatomical knowledge and palpation. Additionally, knowledge of the average measurement results from previous studies is important.

Arterial Vascularization of the Mandibular Condyle and Fractures of the Condyle.

BACKGROUND: Despite substantial displacements, fractures of the mandibular condyle rarely lead to necrosis. This illustrates the negligible role of the inferior alveolar artery in intraosseous supply to the condyle, and led to this systematization of its arterial vascularization. METHODS: Forty-two temporomandibular joints from nonembalmed cadaveric specimens were studied following injection of latex (n = 32) or India ink (n = 10). RESULTS: The intraosseous branches of the inferior alveolar artery that lead to the condyle were inconstant and often rudimentary. In this study, the arteries that consistently led to the condyle were the superficial temporal artery, the deep posterior temporal artery, and arterial branches leading to the lateral pterygoid muscle emanating directly from the maxillary artery. These arteries, along with the transverse facial artery and the masseteric artery (when they participated in condoyle vascularization), formed a quadrangle around the mandibular condyle. After India ink injection, the pterygoid muscle was the most strongly colored muscle, thus indicating substantial vascularization. CONCLUSIONS: Although there is a lack of consensus in the literature regarding the constancy and proportions of the arteries participating in vascularization of the condyle, the superficial temporal artery, the maxillary arterial branches leading to the lateral pterygoid muscle, and the deep posterior temporal artery were constant in this study. This study shows the important role of the lateral pterygoid in the vascularization of the condyle. In case of a fracture with substantial displacement, the vascularization emanating from the superficial temporal artery and the lower alveolar artery is ruptured or compromised.

Ruptured Pseudoaneurysm of the Maxillary Artery and Its Branches Following Le Fort I Osteotomy: Evidence-Based Guidelines.

BACKGROUND: Although rare, pseudoaneurysms (PA) can develop following Le Fort I osteotomy and lead to life-threatening hemorrhage. However, the typical presentation of a PA following a Le Fort I osteotomy is not well characterized. Evidence-based guidelines are not currently available for evaluation of PA following Le Fort I osteotomy. METHODS: A case report is presented of a 27-year-old man who underwent Le Fort I advancement and subsequently developed a bleeding PA. A comprehensive search of journal articles was performed using the MEDLINE/PubMed database between 1964 and April 2016. Keywords and phrases used were "(osteotomy OR craniofacial OR orthognathic) AND (pseudoaneurysm OR aneurysm OR epistaxis)." Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines were followed. RESULTS: The literature search yielded 13 reports of 18 patients. All 18 patients underwent Le Fort I osteotomy and subsequently developed a delayed postoperative bleeding PA. All studies were level IV or V evidence. Twenty-eight percent (N = 5) of the cases documented "excessive" intraoperative bleeding or more than 500 mL of estimated blood loss. The average time for the first bleeding episode and time until final bleed was 17.3 ±â€Š14.3 days (range: 3-62 days) and 27.8 ±â€Š21.2 days following surgery (range: 6-77 days), respectively. Sixty-seven percent (N = 12) had multiple episodes of bleeding. The duration between the bleeding events averaged 10.6 (± 7.9 days) with a range of 1 to 35 days. Bleeding PA's were treated with image-guided embolization (15/18 patients; 83.3%) or ligation or clamping (3/18 patients; 16.7%). CONCLUSION: In the setting of recurrent and/or delayed postoperative epistaxis following Le Fort I osteotomy, surgeons should maintain a high clinical suspicion for PA. Ruptured PA's are often preceded by multiple episodes of progressively worsening epistaxis. Based on the presented case report and pooled data from the literature, angiography is recommended to evaluate for PA in the setting of recurrent epistaxis following Le Fort I osteotomy, especially within the first 4 weeks following surgery.

Benefits of using the ultrasonic BoneScalpel™ in temporomandibular joint reconstruction.

PURPOSE: The main objective of this retrospective study is to analyze and report on our operative experiences and outcomes using the ultrasonic BoneScalpel™ (BoneScalpel) versus a conventional reciprocating saw (RecipSaw) for the purpose of completing the osteotomies in total temporomandibular joint reconstruction (TJR) surgery. MATERIALS AND METHODS: 23 consecutive patients presented with a diagnosis of either degenerative joint disease (n = 23), a failing autogenous TJR (n = 1), heterotrophic bone formation (n = 1) or a subcondylar fracture (n = 1) for a total of 26 joints that received a TJR. 13 unique TJR surgeries employed the use of the BoneScalpel to perform the osteotomies and 13 used the RecipSaw. RESULTS: There was a 49% reduction in the average volume of blood loss in the BoneScalpel group compared to the RecipSaw group (130cc vs. 268cc, p ≤ 0.004), unpaired t-test). For the other variables it was observed that there were more favorable clinical results using the BoneScalpel but without statistically significant differences given the small sample size relative to the prevalence of the outcome that was being measured. CONCLUSIONS: Use of the BoneScalpel in TMJ reconstruction is overall safer and results in less blood loss compared to surgeries employing the use of the conventional RecipSaw for completing osteotomies.

Penetrating foreign body in the masticator space with injury to the internal maxillary artery: a surgical challenge.

INTRODUCTION Foreign bodies (FBs) in the masticator space (MS) are a unique problem because of the difficulty of accessing this deep compartment within the head and neck. In addition, MS contents include critical structures such as the internal maxillary artery (IMA) and mandibular nerve. CASE HISTORY A 39-year-old tradesman was involved in a construction accident whereby a metallic projectile from a machinery drill penetrated his left cheek. Computed tomography revealed a metallic object of dimension 1.9 ×1.2 cm within the MS, with concomitant fracture of left maxillary anterior and lateral walls. Surgery was indicated in view of constant pain and swelling. The FB was removed through the cheek laceration with the aid of an X-ray image intensifier. Persistent significant bleeding was observed within the wound cavity after FB removal that could not be arrested despite attempts at haemostasis with adrenaline packing and oxidised cellulose polymers. Urgent selective left external carotid angiography showed breach of a distal branch of the left internal maxillary artery with contrast extravasation. Embolisation of this branch was undertaken successfully with a liquid agent. CONCLUSIONS This is the first time a FB within the MS with injury to the internal maxillary artery has been described.

Risk of maxillary artery injury during an intraoral vertical ramus osteotomy in Japanese patients is high--is it enough just to avoid damaging the inferior alveolar nerve?

PURPOSE: Since managing a case in which the maxillary artery was injured during intraoral vertical ramus osteotomy (IVRO) with intraoperative transcatheter arterial embolization, we have conducted preoperative vascular computed tomography (CT) evaluations of the maxillary artery course in patients scheduled to undergo mandibular bone osteotomy. The aim of the present study was to describe the anatomy of the maxillary artery in the infratemporal artery in Japanese patients. MATERIALS AND METHODS: The study design was a prospective case series. The study sample included all patients who had undergone IVRO from October 2009 to December 2012. We evaluated the positional relationship between the maxillary artery and the mandible using CT vascular imaging before surgery. The primary outcome variable was the requirement for subperiosteal dissection on the medial surface of the mandible from the perspective of the intersection of the route of the maxillary artery with the IVRO osteotomy line. RESULTS: A total of 156 sides from 78 patients who had undergone mandibular bone osteotomy were included in the present study. The maxillary artery course was positioned directly below the mandibular notch in approximately one half of the cases, necessitating subperiosteal dissection on the medial surface of the mandible. CONCLUSIONS: IVRO is a common surgical procedure that can be safely and easily conducted in conjunction with endoscopy. However, improved maxillary artery damage prevention methods are recommended, such as subperiosteal dissection on the medial surface of the mandible and filling the medial surface of the mandibular ramus with gauze.

Pseudoaneurysm of internal maxillary artery--an untold complication following distraction osteogenesis--a case report.

Pseudoaneurysm of the internal maxillary artery is very rare and only a handful of cases have been reported in the literature thus far and none after placement of a prosthetic condyle and a distraction device. This case report highlights the need for early diagnosis, appropriate steps in management, and a multidisciplinary approach in a tertiary care center in treating this life-threatening condition and proper treatment planning to prevent this condition.

Endoscopic hemostasis with an ultrasonically activated device for hemorrhage from a branch of the maxillary artery during endoscopically assisted reduction of condylar neck fracture.

We describe here a case in which sudden hemorrhage from a branch of the maxillary artery during endoscopically assisted transoral reduction of condylar neck fracture was successfully controlled by endoscopic hemostasis with an ultrasonically activated device.

The immediate lifesaving management of maxillofacial, life-threatening haemorrhages due to IED and/or shrapnel injuries: "when hazard is in hesitation, not in the action".

Maxillofacial/neck vascular injuries caused by improvised explosive devices IEDs or ballistics injuries are life threatening when they cause severe haemorrhage resulting in airway compromise. One should always keep in mind that the best technique used is that which saves the patient's life and not the most expensive and/or technologically advanced. Medical professionals on the scene should have the necessary experience to handle the emergency situations of airway compromise and haemorrhage control. In this instance there is only, "one to a few minutes" to clear airway obstruction and arrest haemorrhage to prevent death. The patients in this study had life-threatening shrapnel injuries of the carotid and/or jugular vessels, and facial primary blast affect implosion of facial middle third air-containing cavities injuries. In a massive casualties arenas, where time=lifesaving, we should need to replace "non-battlefield" civilian techniques with "time driven", combat management for IEDs injuries. In these cases, the immediate and effective compression tamponade using digital, Foley catheter tamponade, packs and/or vessels ligation for severe facial/neck haemorrhage were used successfully.

Iatrogenic pseudoaneurysm: a rare complication of sinonasal surgery.

OBJECTIVE: We report 2 patients with iatrogenic pseudoaneurysms, which developed following sinus surgery. METHOD: Case reports and a review of literature of the management of iatrogenic pseudoaneurysm. RESULTS: For one patient who presented with massive epistaxis, the only lifesaving option available was to perform an urgent angiogram followed by selective embolization of the feeding vessel. In the second patient who presented with persistent nasal obstruction and discharge and no epistaxis, a traumatic aneurysm of the internal carotid artery was demonstrated on magnetic resonance imaging scan that was later confirmed by angiography; he, however, declined further treatment. CONCLUSION: Iatrogenic pseudoaneurysms that develop following a vascular injury, though rare, can cause life-threatening epistaxis or a thromboembolism. In this report, we describe 2 different manifestations of iatrogenic vascular malformations following sinus surgery. The role of angiography and subsequent endovascular therapy in the management of these lesions is emphasized.

Embolization of pseudoaneurysm of the internal maxillary artery after orthognathic surgery.

In orthognathic surgery, Le Fort I osteotomy is one of the most often used methods for the correction of dental-facial deformities and is considered technically safe. However, this procedure may lead to diverse complications, including uncommon vascular complications. A clinical case is described of late development of pseudoaneurysm in one of the branches of the maxillary artery in a 20-year-old patient who had undergone Le Fort I osteotomy, bilateral sagittal osteotomy of mandibular branch, and mentoplasty and subsequently treated with embolization. The main forms of treating vascular injuries are reviewed, and embolization is demonstrated to be a technically safe procedure with few complications.

Endovascular treatment of traumatic pseudoaneurysm presenting as intractable epistaxis.

OBJECTIVE: To investigate the clinical efficacy of individual endovascular management for the treatment of different traumatic pseudoaneurysms presenting as intractable epistaxis. MATERIALS AND METHODS: For 14 consecutive patients with traumatic pseudoaneurysm presenting as refractory epistaxes, 15 endovascular procedures were performed. Digital subtraction angiography revealed that the pseudoaneurysms originated from the internal maxillary artery in eight patients; and all were treated with occlusion of the feeding artery. In six cases, they originated from the internal carotid artery (ICA); out of which, two were managed with detachable balloons, two with covered stents, one by means of cavity embolization, and the remaining one with parent artery occlusion. All of these cases were followed up clinically from six to 18 months, with a mean follow up time of ten months; moreover, three cases were also followed with angiography. RESULTS: Complete cessation of bleeding was achieved in all the 15 instances (100%) immediately after the endovascular therapies. Of the six patients who suffered from ICA pseudoaneurysms, one presented with a permanent stroke and one had an episode of rebleeding requiring intervention. CONCLUSION: In patients presenting with a history of craniocerebral trauma, traumatic pseudoaneurysm must be considered as a differential diagnosis. Individual endovascular treatment is a relatively safe, plausible, and reliable means of managing traumatic pseudoaneurysms.

Maxillary artery pseudoaneurysm after Le Fort I osteotomy: treatment using transcatheter arterial embolization.

Life-threatening hemorrhage is a rare complication after Le Fort I osteotomy. However, owing to the gravity of this complication, all surgeons who perform Le Fort I osteotomy should be aware of the potential for this complication and options for its resolution. The following case report describes an episode of subacute, life-threatening bleeding, after a Le Fort I osteotomy for the treatment of midface hypoplasia. Emergent angiographic evaluation demonstrated an internal maxillary artery pseudoaneurysm with fistulous drainage via the cavernous sinus. This was treated by arterial embolization in which the pseudoaneurysm was packed with microcoils. This report reaffirms the importance of maintaining a high clinical suspicion for pseudoaneurysm as a possible etiology of delayed postoperative bleeding in patients after craniomaxillofacial surgery.

Fístula arteriovenosa postraumática: tratamiento endovascular. Revisión de la literatura y presentación de un caso clínico / Endovascular treatment of a post-traumatic arterio-venous fistula: presentation of a clinical case and literature review

Las fístulas arteriovenosas en la cabeza y el cuello son entidades poco frecuentes. La mayoría es secundaria a heridas penetrantes por arma blanca. Se describe el tratamiento exitoso mediante cirugía endovascular de una fístula postraumática tras una herida penetrante entre la arteria maxilar interna izquierda y la vena yugular externa. A través de este caso clínico y la revisión de la literatura se ilustran las causas, manifestaciones, estudio radiológico y tratamiento de una fístula postraumática entre la arteria maxilar interna y la vena yugular externa. A través de este caso clínico se demuestra la utilidad de los procedimientos endovasculares en el tratamiento de estas complicaciones(AU)

Traumatic arteriovenous fistulas of the head and neck region are uncommon. The majority are due to penetration of blunt injury. We describe a successful endovascular treatment of a posttraumatic fistula between the left maxillary artery and the external jugular vein due to a penetration injury. This case and a review of the literature illustrate the causes, manifestations, image studies and treatment for a posttraumatic fistula between the maxillary artery and the external jugular vein. This case demonstrate the utility of endovascular treatment of head and neck injuries complications(AU)

Endovascular Treatment of Traumatic Pseudoaneurysm Presenting as Intractable Epistaxis

OBJECTIVE: To investigate the clinical efficacy of individual endovascular management for the treatment of different traumatic pseudoaneurysms presenting as intractable epistaxis. MATERIALS AND METHODS: For 14 consecutive patients with traumatic pseudoaneurysm presenting as refractory epistaxes, 15 endovascular procedures were performed. Digital subtraction angiography revealed that the pseudoaneurysms originated from the internal maxillary artery in eight patients; and all were treated with occlusion of the feeding artery. In six cases, they originated from the internal carotid artery (ICA); out of which, two were managed with detachable balloons, two with covered stents, one by means of cavity embolization, and the remaining one with parent artery occlusion. All of these cases were followed up clinically from six to 18 months, with a mean follow up time of ten months; moreover, three cases were also followed with angiography. RESULTS: Complete cessation of bleeding was achieved in all the 15 instances (100%) immediately after the endovascular therapies. Of the six patients who suffered from ICA pseudoaneurysms, one presented with a permanent stroke and one had an episode of rebleeding requiring intervention. CONCLUSION: In patients presenting with a history of craniocerebral trauma, traumatic pseudoaneurysm must be considered as a differential diagnosis. Individual endovascular treatment is a relatively safe, plausible, and reliable means of managing traumatic pseudoaneurysms.

Sudden rupture of the internal maxillary artery causing pseudoaneurysm (mandibular part) secondary to subcondylar mandible fracture.

The mandible is one of the most frequently fractured bones of the face. Condylar fractures are the most common mandibular fractures in adults. The potential complications of mandibular fractures are infection, paresthesia, malunion, nonunion, asymmetry, and long-term functional and growth disturbances. In this article, we report an uncommon case of life-threatening pseudoaneurysm of the internal maxillary artery secondary to subcondylar fracture. We believe that the subcondylar fracture on the vertical vector and oblique direction can damage vital tissues such as the internal maxillary artery, and this injury was, to our knowledge, the first reported acute pseudoaneurysm, which occurred just after the injury at the initial part of the maxillary artery.

Bleeding from posterior superior alveolar artery in Le Fort I fracture.

This article describes a patient in whom significant oronasal bleeding developed after an injury to posterior superior alveolar artery of the maxillary artery in Le Fort I fracture.A 34-year-old man had a facial injury after an explosion of a furnace. Computed tomography demonstrated Le Fort I fracture, right open zygomatic tripod fracture, and open nasal bone fracture. Blood pressure, hemoglobin, and hematocrit levels had fallen to 110/60 mm Hg, 5.7 mg/dL, and 16.1%, respectively, 10 hours after injury despite continuous blood transfusion. Selective digital angiography confirmed an injury to the posterior superior alveolar artery, with extravasated pooling of contrast material in the maxillary sinus. The distal internal maxillary artery was embolized with n-butyl cyanoacrylate and lipiodol. Postembolization angiogram showed resolution of the contrast leak, and the patient's oronasal bleeding resolved.We suggest that if the oronasal bleeding continues in Le Fort fracture, bleeding from the posterior superior alveolar artery should be suspected. In case the vital sign is not stable, selective angiography should be performed before surgery.